Creative enquiry and reflective general practice

DIMENSIONS OF REFLECTION

Creative enquiry has been described in the research world as: ‘... the making of artistic expressions … as a primary way of understanding and examining experience.’ ²

This may involve poetry, photography, painting, or any art form coupled with reflective writing. Creative enquiry allows for imaginative engagement with one’s own experience as well as trying out someone else’s shoes. But why invite creative reflective thinking on practice when creative exploration can feel uncomfortable, unfamiliar, and exposing? A medical student on a creative enquiry module wrote: ‘The arts and the “human side” of medicine are scoffed at by many medical students.’ ³

In this article we draw on our experience within under- and postgraduate education^3,4 to show that the arts can play a significant role in enlarging human understanding through, for example, inviting participants to reframe experiences, engage with multiple perspectives, embrace other languages of expression, and ‘be with’ uncertainty.

Why might these dimensions of reflection be important? Practice is complex. It is the place where we bring our learnt knowledge, skills, values, perspectives, and selves into encounter with our patients;¹ inevitably multifaceted and holistic, it is a ‘swampy lowland’.⁵ Practice requires both self-knowledge and artful navigation of time, space, and the systems we find ourselves in.

In the image (right), a second-year medical student explores the practice of medicine: ‘Doctors can become so focused on what is going on inside the biomedical human body that they can’t hear what is going on inside the person. A doctor can spend all day listening to the heart of a patient, but not for a minute listen to the patient’s heart.’ ⁶

We are positioned to see the doctor in the foreground, with the suffering patient in the background. The doctor ‘listens to the heart’, stethoscope in his ears, but his ears are blocked to the patient suffering by that very same stethoscope — an illustration of an overly narrow and biomedical approach. The image reframes the two competing discourses of competence and caring as intertwined, where a caring doctor will seek to be competent, and the competent doctor will understand that caring enhances the potential for positive therapeutic effect.

WAYS OF SEEING

When medical students reflect on lived experience through visual art, poetry, dance, and other modes of enquiry, this encourages them to create rich descriptions of their developing practice. As students position themselves and engage with their own ‘ways of seeing’ they may become aware of the lenses they bring to a situation, as well as becoming aware of other possible ways of seeing: ‘I found it most liberating! It was interesting to see how everyone interpreted someone’s piece of art, poetry or literature. I really enjoyed listening to other people’s opinions about the play, because a few of them were completely opposite to mine.’(Medical student).³

Listening to a Heart by Tom Cassidy, 2012. Out of our heads. Art in medicine online. http://www.outofourheads.net/oooh/handler.php?id=632.

Creative enquiry invites reflexivity on what students bring to their understanding of a patient story or encounter, for example, how their own situatedness and cultural frameworks affect what they see and hear. In a poem called ‘Paint my Canvas’ written by a first-year medical student after meeting one of her first patients, she describes herself as a ‘blank canvas’ as she listens to a woman who is suffering from a terminal illness:

‘I am a canvas

as blank as can be

Inexperienced in suffering,

Ill-health still a mystery to me.‘

In appraising her own location in the field, that is, not knowing, she responds to this knowledge by listening carefully and with humility. She is aware of her own ‘negative capability’, described by Keats as: ‘... capable of being in uncertainties, mysteries, doubts …’ ⁸

This opens her up to learning with and from her patient.

Developing into a practitioner able to listen, be present, and respond afresh can be encouraged not only through the products of creative enquiry work (such as the poem or picture above), but also by thinking about the process of working with creative materials. The famous sculptor Barbara Hepworth describes how she listens to her materials, allowing the creative work to emerge rather than predetermining what will be produced: ‘My left hand is my thinking hand … It is also a listening hand. It listens for basic weaknesses or flaws in the stone; for the possibility or imminence of fractures.’ ⁹

Listening to patients in this way, yielding from moment to moment to what is emerging, is core to practitioner ways of working.¹ The technician’s solution lies outside of the situation and can usually be found in a book or journal, whereas the practitioner’s solution lies in the situation itself.¹⁰ The ‘right thing to do’ emerges through attending to the practitioner–patient encounter.¹

Such an improvisational participatory approach, that is, inductively, starting where the patient is at rather than confirming or refuting hypotheses (deductive approach), has been shown to enrich the practitioner ‘knowledge’ of the patient and satisfaction in practice, while affording the patient greater sensitivity to their unique personal and social context.¹¹

The arts invite languages of metaphor, colour, texture, sound, silence, and more, allowing practitioners to grapple with the ineffable dimensions of practice. If you knew what a given poem was, you could just write it down. But you’re responding to something you feel claimed by, but can’t yet articulate, or maybe even identify.¹² ‘We know more than we can tell’,¹³ yet medical knowing continues to be narrowly conflated with learning the ‘facts’, citing the ‘evidence’, algorithmic forms of reasoning, and an orientation to communication as a set of ‘skills’.

Creative enquiry, as an example of experiential, aesthetic, and practice-based knowledge construction, has not yet established mainstream recognition, despite its potential to foster different ways of thinking, seeing, and knowing that are so essential to practitioner development.

CRITICAL ENQUIRY INTO PRACTICE

In summary, we believe that the idea of exploring practice through creative enquiry is timely. It offers an alternative to reflection at a time when reflection is falling into disrepute with students and GPs alike. Reflection has to a large extent been hijacked by a tendency to reduce it to an instrumental set of questions, another competency to be documented in one’s e-appraisal, rather than as a process of critical inquiry that — with practice — can indeed unlock discovery, autobiographical development, and emotional sustenance.¹⁴

Being able to think about and enter into our practice affectively and cognitively through the ‘otherness’ of the arts with its different languages, viewpoints, and expressive capabilities, we may come to see ourselves and our practice more clearly. This is an essential starting point for learning and change.